Accidental puncture or laceration in colorectal surgery: a quality indicator or a complexity measure?

Measurement that matters: A systematic review and modified Delphi of multidisciplinary colorectal cancer quality indicators

AIM

To develop a priority set of quality indicators (QIs) for use by colorectal cancer (CRC) multidisciplinary teams (MDTs).

METHODS

The review search strategy was executed in four databases from 2009-August 2019. Two reviewers screened abstracts/manuscripts. Candidate QIs and characteristics were extracted using a tailored abstraction tool and assessed for scientific soundness. To prioritize candidate indicators, a modified Delphi consensus process was conducted. Consensus was sought over two rounds; (1) multidisciplinary expert workshops to identify relevance to Australian CRC MDTs, and (2) an online survey to prioritize QIs by clinical importance.

RESULTS

A total of 93 unique QIs were extracted from 118 studies and categorized into domains of care within the CRC patient pathway. Approximately half the QIs involved more than one discipline (52.7%). One-third of QIs related to surgery of primary CRC (31.2%). QIs on supportive care (6%) and neoadjuvant therapy (6%) were limited. In the Delphi Round 1, workshop participants (n = 12) assessed 93 QIs and produced consensus on retaining 49 QIs including six new QIs. In Round 2, survey participants (n = 44) rated QIs and prioritized a final 26 QIs across all domains of care and disciplines with a concordance level > 80%. Participants represented all MDT disciplines, predominantly surgical (32%), radiation (23%) and medical (20%) oncology, and nursing (18%), across six Australian states, with an even spread of experience level.

CONCLUSION

This study identified a large number of existing CRC QIs and prioritized the most clinically relevant QIs for use by Australian MDTs to measure and monitor their performance.

2023 WSES guidelines for the prevention, detection, and management of iatrogenic urinary tract injuries (IUTIs) during emergency digestive surgery

Iatrogenic urinary tract injury (IUTI) is a severe complication of emergency digestive surgery. It can lead to increased postoperative morbidity and mortality and have a long-term impact on the quality of life. The reported incidence of IUTIs varies greatly among the studies, ranging from 0.3 to 1.5%. Given the high volume of emergency digestive surgery performed worldwide, there is a need for well-defined and effective strategies to prevent and manage IUTIs. Currently, there is a lack of consensus regarding the prevention, detection, and management of IUTIs in the emergency setting. The present guidelines, promoted by the World Society of Emergency Surgery (WSES), were developed following a systematic review of the literature and an international expert panel discussion. The primary aim of these WSES guidelines is to provide evidence-based recommendations to support clinicians and surgeons in the prevention, detection, and management of IUTIs during emergency digestive surgery. The following key aspects were considered: (1) effectiveness of preventive interventions for IUTIs during emergency digestive surgery; (2) intra-operative detection of IUTIs and appropriate management strategies; (3) postoperative detection of IUTIs and appropriate management strategies and timing; and (4) effectiveness of antibiotic therapy (including type and duration) in case of IUTIs.

A retrospective study of the effects of minimally invasive colorectal surgery on Patient Safety Indicators across a five-hospital system

BACKGROUND

The Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals.

METHODS

A health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13.

RESULTS

There were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15.

CONCLUSION

Understanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued.

Near-infrared fluorescent solid material for visualizing indwelling devices implanted for medical use

BACKGROUND

In clinical practice, various devices are implanted into the body for medical reasons. As X-ray fluoroscopy is necessary to visualize medical devices implanted into the body, the development of a less-invasive visualization method is highly desired. This study aimed to investigate the clinical applicability of our novel solid material that emits near-infrared fluorescence.

METHODS

We developed a solid resin material that emits near-infrared fluorescence. This material incorporates a near-infrared fluorescent pigment, with quantum yield ≥ 20 times than that of indocyanine green. It can be sterilized for medical treatment. This resin material is designed to be molded into a catheter and inserted into the body with an endoscope clip. In this preclinical experiment using a swine model, the resin material was embedded into the body of the swine and visualized with a near-infrared fluorescence camera system.

RESULTS

Endoscopic clips were placed in the mucosa of the stomach, esophagus, and large intestine, and the indwelling ureteral catheters were successfully visualized by near-infrared fluorescence laparoscopy.

CONCLUSIONS

We confirmed the tissue permeability of the fluorescence emitted by our novel near-infrared fluorescent material and the possibility of its clinical application. This material may allow visualization of devices embedded in the body.

Detailed and applied anatomy for improved rectal cancer treatment

Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.

Impact of Intra-Operative Adverse Events on the Risk of Surgical Site Infection in Abdominal Surgery

BACKGROUND

Intra-operative adverse events (iAEs) recently were shown to correlate independently with an increased risk of post-operative death, morbidity, re-admissions, and length of hospital stay. We sought to understand further the impact of iAEs on surgical site infections (SSIs) in abdominal surgical procedures and delineate which patient populations are most affected. We hypothesized that all patients with iAEs have an increased risk for SSI, especially those with pre-existing risk factors for SSI.

PATIENTS AND METHODS

To identify iAEs, a well-described three-step methodology was used: (1) the 2007-2012 American College of Surgeons-National Surgical Quality Improvement Program database was merged with the administrative database of our tertiary academic center, (2) the merged database was screened for iAEs in abdominal surgical procedures using the International Classification of Diseases, Ninth Revision, Clinical Modification-based Patient Safety Indicator "Accidental Puncture/Laceration," and (3) each flagged record was systematically reviewed to confirm iAE occurrence. Uni-variable and backward stepwise multi-variable analyses (adjusting for demographics, co-morbidities, type and complexity of operation) were performed to study the independent correlation between iAEs and SSIs (superficial, deep incisional, and organ-space). The correlation between iAEs and SSIs was investigated especially in patients deemed a priori at high risk for SSIs, specifically those older than age 60 and those with diabetes mellitus, obesity, cigarette smoking, steroid use, or American Society of Anesthesiologists class ≥III.

RESULTS

A total of 9,288 operations were included, and iAEs were detected in 183 (2.0%). Most iAEs consisted of bowel (44%) or vessel (29%) injuries and were addressed intra-operatively (92%). SSI occurred in 686 (7.4%) cases and included 331 (3.5%) superficial, 32 (0.34%) deep incisional, and 333 (3.6%) organ/space infections. iAEs were correlated independently with SSI (odds ratio [OR] = 1.67; 95% confidence interval [CI], 1.11-2.52, p = 0.013), and more severe iAEs were associated with a higher risk of infection. Analysis by SSI type revealed a significant association with organ/space SSI (OR = 1.81, 95% CI 1.07-3.05; p = 0.027), but not incisional infections. Most interestingly, the occurrence of an iAE was correlated with increased SSI rate in the low-risk but not the high-risk patient populations. Specifically, iAEs increased SSI in patients younger than 60 (OR = 2.69, 95% CI 1.55-4.67, p < 0.001), non-diabetic patients (OR = 1.64, 95% CI 1.04-2.58, p = 0.034), non-obese patients (OR = 2.9, 95% CI 1.81-4.66, p < 0.001), non-smokers (OR = 1.67, 95% CI 1.08-2.6, p = 0.022), with no steroid use (OR = 1.73, 95% CI 1.15-2.6, p < 0.008), and with ASA class <III (OR = 2.26, 95% CI 1.31-3.87, p = 0.003).

CONCLUSIONS

The iAEs are associated independently with increased SSIs, particularly in patients with less pre-existing risk factors for SSI. Preventing iAEs or mitigating their impact, once they occur, may help decrease the rate of SSIs.

Impact of inadvertent enterotomy on short-term outcomes after ventral hernia repair: An AHSQC analysis

BACKGROUND

Patients undergoing ventral hernia repair (VHR) are at risk of an inadvertent enterotomy during surgery. Inadvertent enterotomies potentially contaminate the surgical field presenting a management dilemma for the surgeon. The aim of our study was to define the incidence and risk factors for a recognized inadvertent enterotomy and determine its impact on short-term outcomes after ventral hernia repair.

METHODS

Using a nationwide hernia registry, the Americas Hernia Society Quality Collaborative, we reviewed all ventral hernia repair performed between 2013 and 2017. Patients were assessed for full-thickness inadvertent enterotomies at the time of surgery. Patients with inadvertent enterotomies and without enterotomies were compared to assess differences in 30-day outcomes, using regression modeling.

RESULTS

A total of 5,916 patients were included. The incidence of inadvertent enterotomy was 1.9%, with no difference between open and laparoscopic approaches. Inadvertent enterotomies did not increase surgical site occurrences but there were more surgical site infections (OR: 2.20 [95% CI: 1.24-3.90], P = .007). Patients were less likely to receive mesh if there was an enterotomy. Inadvertent enterotomies led to higher rates of reoperations, readmission, enterocutaneous fistulas, and mortality.

CONCLUSION

Inadvertent enterotomies are more common in complex cases of ventral hernia repair and have an overall incidence of 1.9%. These patients are at increased risk of surgical site infections, reoperations, readmission, and mortality. Although definitive hernia repair with mesh can be safely performed, surgeons should consider multiple factors, including type of mesh and location of mesh in the abdominal wall, before proceeding with definitive repair in any case of an enterotomy.

Defining the association between operative time and outcomes in children's surgery

INTRODUCTION

Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery.

METHODS

182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups. OT for each group was analyzed by quartile, and regression models were used to determine the relationship between prolonged OT and complications.

RESULTS

Variations in OT existed for both short and long procedures. Cases in the longest quartile had twice the odds of postoperative complications after adjusting for age, sex and BMI (OR 1.85; 95% CI 1.78-1.91). Procedure-specific prolonged OT was associated with postoperative complications for the majority (85%) of procedural groupings. Prolonged OT was associated with minor complications in gynecologic (OR 4.17; 95% CI 2.19-7.96), urologic (OR 2.88; 95% CI 2.40-3.44), and appendix procedures (OR 2.88; 95% CI 2.49-3.34). There were increased odds of major complications in foregut (OR 6.56; 95% CI 4.99-8.64), gynecologic (OR 3.07; 95% CI 1.84-5.13), and spine procedures (OR 2.99; 95% CI 2.57-3.28).

CONCLUSIONS

Prolonged OT is associated with increased odds of postoperative complications across a spectrum of children's surgical procedures. Factors contributing to prolonged OT merit further investigation and may serve as a target for future quality improvement.

LEVEL OF EVIDENCE

Level III.

Clinical validity and relevance of accidental puncture or laceration as a patient safety indicator for children

PURPOSE

Accidental puncture or laceration (APL) has been endorsed as a patient safety indicator and is being used to compare hospital performance and for reimbursement. We sought to determine the positive predictive value (PPV) of APL as a quality metric in a pediatric population.

METHODS

We retrospectively reviewed all cases that met APL administrative criteria over 5years in a quaternary pediatric hospital system. Events were categorized as false positive (FP) or true positive (TP). TP cases were further categorized as "potentially consequential" or "inconsequential". The PPV of APL was calculated, and a z-test was used to provide 95% confidence intervals.

RESULTS

Of the 238 cases identified, 204 were categorized as TP (86%; 95% CI: 80%-90%). Thirty-four of these events (17%) involved injuries that were considered "inconsequential". True events that required repair were identified as "potentially consequential" (n=170). Thus, the PPV of APL was 71% (95% CI: 65%-77%). Extenuating factors such as adhesive disease or abnormal anatomy were present in 39% of TP cases. Thirty-four cases (14%) were categorized as FP because no documented injury was found.

CONCLUSIONS

A large proportion of APL events are either false or clinically irrelevant, thus questioning its usability as a patient safety indicator for children undergoing surgery.

TYPE OF STUDY

Retrospective review.

LEVEL OF EVIDENCE

IV.

Inadvertent Splenectomy During Resection for Colorectal Cancer Does Not Increase Long-term Mortality in a Propensity Score Model: A Nationwide Cohort Study

BACKGROUND

Previous studies suggest that long-term mortality is increased in patients who undergo splenectomy during surgery for colorectal cancer. The reason for this association remains unclear.

OBJECTIVE

The purpose of this study was to investigate the association between inadvertent splenectomy attributed to iatrogenic lesion to the spleen during colorectal cancer resections and long-term mortality in a national cohort of unselected patients.

DESIGN

This was a retrospective, nationwide cohort study.

SETTINGS

Data were collected from the database of the Danish Colorectal Cancer Group and merged with data from the National Patient Registry and the National Pathology Databank.

PATIENTS

Danish patients with colorectal cancer undergoing curatively intended resection between 2001 and 2011 were included in the study.

MAIN OUTCOME MEASURES

The primary outcome was long-term mortality for patients surviving 30 days after surgery. Secondary outcomes were 30-day mortality and risk factors for inadvertent splenectomy. Multivariable and propensity-score matched Cox regression analyses were used to adjust for potential confounding.

RESULTS

In total, 23,727 patients were included, of which 277 (1.2%) underwent inadvertent splenectomy. There was no association between inadvertent splenectomy and long-term mortality (adjusted HR = 1.15 (95% CI, 0.95-1.40); p = 0.16) in the propensity score-matched model, whereas 30-day mortality was significantly increased (adjusted HR = 2.31 (95% CI, 1.71-3.11); p < 0.001). Inadvertent splenectomy was most often seen during left hemicolectomy (left hemicolectomy vs right hemicolectomy: OR = 24.76 (95% CI, 15.30-40.06); p < 0.001).

LIMITATIONS

This study was limited by its retrospective study design and lack of detailed information on postoperative complications.

CONCLUSIONS

Inadvertent splenectomy during resection for colorectal cancer does not seem to increase long-term mortality. The previously reported reduced overall survival after inadvertent splenectomy may be explained by excess mortality in the immediate postoperative period.

Patient Safety Indicators for Judging Hospital Performance

Patient Safety Indicators (PSIs) were originally intended for use as a screen for quality of care but are now being used to rank hospitals and to modify hospital reimbursement. PSI data are dependent on accuracy of clinical documentation and coding. Information on whether a PSI event is inherent to the nature of the operation or posed a significant impact on the outcome is lacking. Cases for one year at a single academic center were queried. Cases with target PSIs were included (n = 136). Cases were evaluated for both the inherent nature and significance of injury. Both patient safety officers agreed that the PSI event was inherent to the disease process, and thus, the procedure and was not a marker of patient safety (false positive) in 11.8% to 33.3% of cases. Both reviewers agreed that the events were not clinically significant in 11.8% to 30.4% of cases. This study found high false-positive rates and only moderate interrater reliability for 3 PSIs. PSIs as currently reported are not reliable enough to be utilized for ranking.

Complex and Reoperative Colorectal Surgery: Setting Expectations and Learning from Experience

A range of topics are covered in this issue dedicated to complex and reoperative colorectal surgery, from radiation-induced surgical problems, to enterocutaneous fistulas and locally advanced or recurrent rectal cancer. Common themes include the importance of operative planning and patient counseling on the expected functional outcomes. Experts in the field offer their technical tips and clinical lessons to maximize outcomes and minimize complications in these challenging cases.

CT Scan Mapping of Splenic Flexure in Relation to Spleen and its Clinical Implications

Splenic flexure mobilization is a challenging step during left colon resection. The maneuver places the spleen at risk for injury. To minimize this risk, we conducted this study for CT scan mapping of splenic flexure in relation to the spleen. One hundred and sixty CTscans of abdomen were reviewed. The level of the splenic flexure was determined in relation to hilum and lower pole of spleen. These levels were compared with patient demographics. Statistical analysis was performed using Fisher's exact test. The splenic flexure was above the hilum of the spleen in 95 patients (67.86%), at the splenic hilum level in 11 patents (7.88%), between the hilum and lower pole of the spleen in 12 (8.57%), at the lower pole of the spleen in 15 (10.7%) patients and 7 (5%) patients has a splenic flexure that lied below the lower pole of the spleen. Patient demographics showed no statistical significance in regard to splenic flexure location. Splenic flexure lies above the hilum of the spleen in majority of patients. This should be considered as part of operative strategies for left colon resection.

Risk of Intraoperative Injury of Nearby Structures: National Trend, Distribution, and Burden

BACKGROUND

Accidental injury of a nearby structure during surgical operations carries a risk of serious morbidity and mortality. Furthermore, it represents a medico-legal liability. We aimed to examine the national distribution, cost, and trend of accidental intraoperative injuries.

STUDY DESIGN

We performed a cross-sectional study using the Nationwide Inpatient Sample database. The study population consisted of patients who encountered intraoperative injuries between 2003 and 2010. Controls were randomly selected from patients who underwent similar procedures during the same period. Cost was adjusted for inflation rate to reflect 2015 dollar values.

RESULTS

A total of 61,667 cases with intraoperative injuries and 430,424 controls were included. Intraoperative injuries were most common in procedures that involved the digestive system (38.0%), female reproductive organs (21.4%), and musculoskeletal system (12.2%). There was a significant increase in those injuries from 161.3 cases/100,000 procedures in 2003 to 254.9 cases/100,000 procedures in 2010 (p < 0.001). Female sex, pediatric and older populations, overweight, trauma and teaching hospital were all independent risk factors of injuries in the multivariate model (p < 0.05 for all). Intraoperative injuries were associated with a higher risk of concomitant complications (odds ratio [OR] 2.44, 95% CI 2.36, 2.54, p < 0.001) and hospital mortality risk (OR 2.33, 95% CI [2.15, 2.51], p < 0.001). Nationally, it is estimated that injuries of nearby structures resulted in an annual average of 84,708.7 days of excess hospital admission days and $426.33 million excess cost.

CONCLUSIONS

Certain demographic and clinical factors influence the risk of intraoperative injury of nearby structures. The prevalence of intraoperative injuries is increasing at the national level, and these injuries are associated with increased mortality and pose substantial clinical and financial burdens.

Reconciliation of international administrative coding systems for comparison of colorectal surgery outcome

AIM

Significant variation in colorectal surgery outcomes exists between different countries. Better understanding of the sources of variable outcomes using administrative data requires alignment of differing clinical coding systems. We aimed to map similar diagnoses and procedures across administrative coding systems used in different countries.

METHOD

Administrative data were collected in a central database as part of the Global Comparators (GC) Project. In order to unify these data, a systematic translation of diagnostic and procedural codes was undertaken. Codes for colorectal diagnoses, resections, operative complications and reoperative interventions were mapped across the respective national healthcare administrative coding systems. Discharge data from January 2006 to June 2011 for patients who had undergone colorectal surgical resections were analysed to generate risk-adjusted models for mortality, length of stay, readmissions and reoperations.

RESULTS

In all, 52 544 case records were collated from 31 institutions in five countries. Mapping of all the coding systems was achieved so that diagnosis and procedures from the participant countries could be compared. Using the aligned coding systems to develop risk-adjusted models, the 30-day mortality rate for colorectal surgery was 3.95% (95% CI 0.86-7.54), the 30-day readmission rate was 11.05% (5.67-17.61), the 28-day reoperation rate was 6.13% (3.68-9.66) and the mean length of stay was 14 (7.65-46.76) days.

CONCLUSION

The linkage of international hospital administrative data that we developed enabled comparison of documented surgical outcomes between countries. This methodology may facilitate international benchmarking.

Management of iatrogenic ureteral injury

Iatrogenic injury to the ureter is a potentially devastating complication of modern surgery. The ureters are most often injured in gynecologic, colorectal, and vascular pelvic surgery. There is also potential for considerable ureteral injury during endoscopic procedures for ureteric pathology such as tumor or lithiasis. While maneuvers such as perioperative stenting have been touted as a means to avoid ureteral injury, these techniques have not been adopted universally, and the available literature does not make a case for their routine use. Distal ureteral injuries are best managed with ureteroneocystostomy with or without a vesico-psoas hitch. Mid-ureteral and proximal ureteral injuries can potentially be managed with ureteroureterostomy. If the distal segment is unsuitable for anastomosis then a number of techniques are available for repair including a Boari tubularized bladder flap, transureteroureterostomy, or renal autotransplantation. In rare cases renal autotransplantation or ureteral substitution with gastrointestinal segments may be warranted to re-establish urinary tract continuity. Laparoscopic and minimally invasive techniques have been employed to remedy iatrogenic ureteral injuries.